Become A Couple Client

Date

Month

Day

Year

Partner 1 Full Name

Partner 2 Full Name

Best Email for Communication (use a ; to separate emails)

Phone (only one at this time)

At leaset one of us is a resident in Maryland.

We both are NOT residence of Maryland.

What Service Are You Interested In?

One or Both Parties Identify With The Following Statement.

I currently have thoughts or desire to harm myself or someone else.

I have a history of suicide attempts or suicidal ideation.

Both Apply

None Apply

Would you like a 15 minute introduction call?

Yes, I would like a 15 minute introduction call.

No, I am ready to schedule my first session.

How did you hear about my services?

Yes, subscribe me to recieve email and SMS notifcations.

Please allow 24-48 business hours for a response. If you are experiencing an emergency, please stop and call 911.